Medical situations can instantly change. This can be for the better or for the worse: A patient who consistently refused to eat, now suddenly decides to eat. A patient who is delirious or manic threatens a staff member at 11:50, but subsequently seems rational and reasonable when we arrive in his room 15 minutes later. A stroke patient who does not communicate or respond, and who is likely to develop into a permanent vegetative state (PVS), perks up, talks and leaves. A patient, who is on the mend, develops a fever, requires a rapid response and dies.

The ethical issues, similarly, change instantly in these situations. It requires me, as a new clinical ethics, to constantly redefine my perspectives. Where we plan to discuss placement of a feeding tube, the patient’s mood alteration resolves issues around placement and resolves the ethical questions. Where we address concerns around a safe discharge, we find out that the patient’s mood changes at 12 o' clock, and awareness of this time frame allows for a safe discharge. Where have family meetings to discuss quality of life in a PVS, this discussion is no longer necessary as the patient can be discharged.

Death seems a static event, compared to the other events in the medical context. Yet, this does not mean an absence of controversies. Controversy exists about when death is declared (1), how to determine death (2), the meaning of death (3), whether death is a social construct or a scientific one (4), and organ donation after death (5).

This week I observed a brain death examination. It was a very careful and time consuming process, where the physician ruled out any doubt whether or not the brain death criteria were fulfilled. Due process and examination sought to ensure that nothing is missed, and to rule out the possibility of instant changes. It involved, amongst other things, testing of pain reflexes, reflexes of pupils and their responsiveness to light, testing of ocular movement, oxygen intake or an apnea test, and blood tests. Questions around the following controversies came into my mind:

The USA and the UK have different criteria for defining brain death. This gives rise to some theoretical controversy. The USA proceeds from the whole brain death criterion, versus the UK which proceeds from the brain stem death criterion. Truog & Miller (6) set out , fairly comprehensively, what the distinction between the two definitions and the controversies entail. They describe that the US system depends on defining death as “the loss of integrated functioning of the organism as a whole”. Controversy, according to their notes, exists because unless we switch off all machines, eradicating all possibilities of organ retention, this criterion cannot be fulfilled. Organs keep functioning on the ventilator despite brain death. Hence, there will not be a loss of integrated functioning. Truog offers the example of a pregnant brain death woman, who is kept on the ventilator to deliver a viable baby; her system was not disintegrated, for she could still ‘incubate’ the baby and allow the baby to develop. The UK system, by contrast, proceeds from the brain stem death criterion, which is based on 2 elements, i.e. breathing and consciousness. Controversy under this criterion arises as the absence of consciousness can only be approached by tests. There are no exact tests, and tests can only approximate the absence of consciousness by exclusion; as no other system works, the consciousness system is unlikely to work too. Moreover, controversy may arise as the UK criterion does not require any other loss of functions. So some ‘basic’ biological functions may still exist, while the person is basically (brain) dead. For example, it may be possible that the person still excretes, while his/her brain is dead.

The debate around defining death and brain death is far from static. Death is controversial by its nature and so is its definition. The debate is transient and ongoing with developing technologies and political strategies. Authors as Truog and Miller attribute the transient definitions of brain death, to strategies around organ donation. Recently, when Canada changed its brain death criteria, controversy flared up along the lines of organ donation strategies. Defining death is perhaps as hard as defining life and consciousness. In my clinical ethics career I’ve asked: What is the value of life, and the value of defining life? Perhaps it is necessarily to turn this question around and ask: What is the value of death, and the value of defining death? What does death stand for in a clinical ethics environment?

Truog, Robert D, & Robinson, W. M. (2003). Role of brain death and the dead-donor rule in the ethics of organ transplantation. Critical care medicine, 31(9), 2391–6. doi:10.1097/01.CCM.0000090869.19410.3C

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Comments

Thank you for this article on the update of ethical considerations of brain death. It seems to me that all the controversy arose when organ transplants became a commercial enterprise. Vigilance and moral balance are demanded by all in the medical profession for death is the common destiny for all of us.

Therein, a new rationale for the appropriateness of declaring death by neurologic criteria is proposed - one that differs from the "loss of integrated functioning" rationale discussed above. (See page 58 of the white paper.)

This new rationale can briefly be described as "loss of the ability to do the fundamental work of a living organism." I find this rationale persuasive.

It seems as if the more we advance with medical care and technologies, the more difficult the decision making for the physicians. Doctors are still human after all, but often they are expected to make the perfect decision at every moment.